Overview of Medicaid and the 1115 Medicaid Transformation Waiver Opportunities for Supportive Housing Providers and Tenants August 2, 2016
Speaker Carol Wilkins, MPP Consultant carol.wilkins.ca@gmail.com 2
How can we pay for the services homeless people need? How can Medicaid and other resources in health care system pay for effective care including the SUPPORT that helps people get and keep housing? 3
Medicaid is a partnership between state and federal government with shared costs Federal law and policy provides the framework for federal matching funds and some program requirements States make important choices about coverage expansion, benefit design, optional benefits, delivery system, provider qualifications, payment rates, and waiver requests Medicaid and solutions to homelessness Center for Medicare and Medicaid Services (CMS) establishes policies, approves State Medicaid Plans and waivers, and provides oversight Medicaid services can help people get and keep housing Federal policy does not allow Medicaid to pay for room and board Some Medicaid services can be delivered in supportive housing or in other settings where homeless people get help Funding from HUD or other homeless programs often pays for some services that could be covered by Medicaid Service providers may be able to access Medicaid reimbursement Medicaid services can help meet the needs of people who are experiencing homelessness or living in supportive housing Partnerships can connect Medicaid providers with organizations that deliver housing to meet the needs of shared clients People living in supportive housing can get more care and supports 4
Effective service strategies Helping people get and keep housing Outreach and assertive, patient engagement to overcome barriers resulting from isolation and symptoms of mental illness or addiction Establishing trust and restoring hope Trauma informed services Enhancing motivation to change harmful / risky behaviors Delivering or connecting people to the care they need for health, mental health, and substance use disorders Practical support to meet basic needs and respond to individual preferences and goals Skill-building for community living 5
Housingrelated services that may be covered by Medicaid CMS Informational Bulletin June 26, 2015 Individual housing transition services Supporting an individual s ability to prepare for and transition to housing Individual housing and tenancy sustaining services Services that support the individual in being a successful tenant in his/her housing arrangement State-level housing-related collaborative activities Services to support collaborative activities across public agencies to assist a state in identifying and securing housing options for Individuals with disabilities Older adults needing LTSS People experiencing chronic homelessness 6
Necessary for Medicaid financing Covered service Using an authority established by federal law Most services delivered outside of hospitals and doctors offices are optional benefits established by agreement between state and CMS (State Plan or waiver) Eligible person Enrolled in Medicaid - and Medical necessity for these services = services are appropriate based on health-related needs and likely to be effective Qualified provider and setting in which service are delivered State establishes qualifications and procedures for becoming a provider of Medicaid covered services Managed care plans may be selective and have additional requirements 7
Medicaid authorities sometimes used to cover services linked to housing Rehabilitative Services Targeted Case Management Federally Qualified Health Centers (FQHC) Home and Community Based Services 1915(c) Waiver services for people eligible for nursing home level of care 1915(i) State Plan Health Home Services Medicaid Waivers 1115 1915(b) Waivers must be cost neutral to federal government in Medicaid program 8
Medicaid for services linked to supportive housing current practices Most often Medicaid is covering mental health services that can be mobile and connected to supportive housing / rent subsidies To be eligible, a person must have a serious mental illness Rehabilitative services must address functioning impaired by mental illness, and must be related to goals in a service plan Some Federally Qualified Health Centers (FQHC) also provide services in homeless shelters, street outreach, and supportive housing Medicaid payments for visits with doctors (including psychiatrist), mid-level practitioners (Nurse Practitioner, Physician Assistant), LCSW or clinical psychologist Integrated primary care and behavioral health services Often partnerships use both Medicaid payment models 1115 waivers provide opportunities to use Medicaid financing to test new models and pay for services not otherwise matchable 9
Funding from other sources is needed to cover what Medicaid doesn t pay for through direct reimbursement Medicaid cannot pay for room and board With current benefits, Medicaid reimbursement often is not available for some services people may need: Outreach and engagement to find people and build trust Motivating a person to participate in assessment and treatment planning and to establish recovery goals Accompanying a person to medical appointments Some services that focus on harms related to substance use for persons with other chronic health conditions Home visits by nurses and other health workers for engagement and care coordination, and to monitor health-related needs Helping people with basic needs (food, transportation, utilities) Some services that focus directly on finding housing, qualifying for housing assistance and other benefits, negotiating with landlords to prevent eviction Services delivered by organizations that are not established as qualified providers of Medicaid services Medicaid 1115 waivers can provide opportunities to invest in delivery system capacity and pay for some of these services 10
Evolving mix of payment mechanisms for service providers Value Based Purchasing: States and health plans are shifting from paying for volume to paying for value Fee for service Usually for encounters or minutes of service Sometimes for a bundle of services (episode, day, or month) Case rates Capitation Per member per month payment for defined set of services Some flexibility for health plans and delivery systems to pay for interventions to improve quality and reduce need for hospital services Sometimes with financial incentives for controlling utilization & costs (shared risk / savings) and meeting quality goals Delivery system improvement Investments to build capacity and support innovation in the system Incentive payments tied to milestones and system-level improvements Grants and contracts for programs May pay for costs not covered by Medicaid reimbursement 11
Medicaid for services in supportive housing collaborations with hospitals and health plans Capitation creates incentives for hospitals and health plans to coordinate care and pay for services that improve quality and reduce avoidable costs Some hospitals are paying for medical respite / recuperative care and intensive case management for frequent users Medicaid managed care plans in some states are paying for services in partnership with CoCs and supportive housing Care coordination delivered face to face by trusted service providers who can find and engage homeless members Diversionary services to reduce avoidable hospitalizations by providing community support Case management services linked to housing assistance Federal regulations for Medicaid managed care recognize service coordination, case management, and activities supporting community integration of individuals with complex needs as activities that improve health care quality (MLR calculation) 12
Washington State is negotiating with CMS for approval of waiver Proposal submitted August 2015 http://www.hca.wa.gov/hw/pages/medicaid_transformation.aspx Washington s Medicaid Transformation Waiver proposal Three Initiatives 1. Transformation through Accountable Communities of Health ACHs will implement transformation projects Incentive payments for providers and community partners engaging in efforts that drive delivery system toward better outcomes 2. Broaden the array of service options that enable individuals to stay at home and delay or avoid the need for more intensive care 3. Provide targeted foundational community supports Supportive housing Supported employment 13
Reduce avoidable use of intensive services and settings Hospitals, nursing homes, jails, psychiatric hospitals, traditional long term services and supports Waiver Transformation Goals Improve population health Focus on prevention and management of conditions such as diabetes, cardiovascular disease, smoking, mental illness and substance use disorders Accelerate the transition to value-based payment Payment methods shift from fee-for-service and consider quality of services and other measures of value Ensure that Medicaid per-capita cost growth is below national trends Also Waiver provides incentives to develop infrastructure and support changes that can be sustained after 5-year waiver period 14
Lots of changes in health care payment and delivery systems Health System Transformation also includes Integration of primary care and behavioral health services Better integration of care and social supports to address health and recovery needs of the whole person Leverage and align data Health systems capacity building Support for practice transformation Workforce capacity planned or in progress 15
Initiative 1 Transformation through Accountable Communities of Health Affordable and supportive housing providers participate in ACH cross-sector collaboration for planning to address local priority health needs and transformation objectives Transformation project ideas to drive health care delivery systems toward better health outcomes Some projects could help participating supportive housing providers build capacity to engage in health sector partnerships and use Medicaid reimbursement Supportive housing can make significant contributions to outcomes expected under value-based payment arrangements Care delivery redesign can strengthen integrated systems of community support for people who live in supportive housing 16
Initiative 3 Supportive Housing work in progress Defining who is eligible to receive proposed supportive housing benefit Medically necessary Defining what types of providers can receive Medicaid reimbursement for proposed supportive housing services What types of organizations and staff skills / credentials? Limited scope license / certification Establishing payment mechanisms for supportive housing services Funding to providers through BHOs and MCOs Defining service encounters Rate setting 17
Supportive Housing Services DRAFT proposed definition Includes client-specific services: Identifying housing options with focus on choice and preferences Assisting with housing & subsidy applications Help to prepare for move-in: negotiate lease agreements, get furnishings and household items Supporting individual in housing: independent living skills coaching, access to community resources Reminders for medications, monitoring symptoms, crisis coping skills, recovery management Mediating relationships with landlords, neighbors Linkages to education, job skills, employment Linkages to health care providers Education on rights and responsibilities of tenants Does NOT include any funds to pay for rent, subsidies, utilities, building housing, room and board 18
Implications for service providers Medicaid reimbursement is not the same as grant or contract funding for program costs Need to document That individual needs covered services That covered services have been provided to eligible person New types of contracts and agreements with some new partners BHOs, MCOs, and ALTSA/HCS Other providers with capacity to meet some requirements? May need to increase staff skills and provide (or contract for) clinical support/ supervision To meet licensure requirements and other standards or contract terms To effectively engage consumers and achieve better health outcomes To collaborate with new partners and service systems New / improved administrative infrastructure To support documentation and claiming To facilitate coordination with health care delivery system and other supports 19
HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) Medicaid and Permanent Supportive Housing for Chronically Homeless Individuals: Emerging Practices from the Field (2014) A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing (2014) Resources CMS Informational Bulletin (June 2015) http://www.medicaid.gov/federal-policy-guidance/downloads/ CIB-06-26-2015.pdf RWJ Foundation State Health and Value Strategies http://statenetwork.org/resource/improving-care-for-medicaidbeneficiaries-experiencing-homelessness/ http://statenetwork.org/resource/webinar-improving-care-formedicaid-beneficiaries-experiencing-homelessness/ 20